HOME BUILDERS SUPPLEMENTAL INSURANCE APPLICATION

Transcription

1 HOME BUILDERS SUPPLEMENTAL INSURANCE APPLICATION IMPORTANT: SUBMITTING AN APPLICATION DOES NOT BIND COVERAGE NOTE: Do not leave any questions blank. If it does not apply, mark it "N/A." HOW TO COMPLETE THIS FORM Whoever fills out the form must be a principal, partner or director of the applicant firm and should make all the necessary enquiries of their fellow partners, directors and employees to enable all the questions to be answered. If you require any extra space to complete the answers to questions contained within this application form please continue your response on an additional sheet of paper and attach it to this application. Once you have completed the form please return directly to your insurance broker. SECTION 1: COMPANY DETAILS 1. Please complete the following: Applicant Name: Doing Business As (DBA): Street Address: City: State: Zip: Telephone: Fax: Website: Legal Status: Individual Partnership Corporation Joint Venture For Profit n-profit Tax Exempt Other Mailing Address: City: State: Zip: Area of Operations: Insurance Contact: 2. Years in business: Total experience in this type of business: FEIN: 3. Please state the number of employees: Full-time: Part-time: 4. Licenses Held: License Type Contract: License Number Seasonal: Page 1 of 5

2 5. Payroll: Owners/Partners: $ Employees: $ 6. Projected cost subcontracted work (labor & materials): Insured: $ Uninsured: $ 7. Total receipts: $ SECTION 2: OPERATIONS 1. Provide a description of the type of work done by you and your employees: 2. Have you operated under any other name or names? If yes, please provide prior name and describe type of operations: 3. Have you been involved as a General Contractor in the building of condiminiums, apartments, or townhouses in the past 10 years? 4. Have you ever been or are you currently involved in any new residential construction of tract homes, condos, apartments, townhomes, or custom homes? If yes, please specify year(s), number(s), and location(s): 5. What is the average dollar value of a completed project? $ 6. Please descibe any types of projects that you have discontinued (i.e., no longer build, etc.): 7. What is the projected number of starts anticipated for the upcoming policy year? 8. What is the average number of homes in any single development where you build: What is the maximum number? 9. What is the average number of homes you build in any single development? What is the maximum number? 10. Do yo uhave an independent inspection performed on your homes prior to release to owner? 11. Would you be willing to have an independent inspection performed on your homes prior to release to owners? 12. Does an employee of the applicant have direct oversight of each jobsite in progress? 13. Are you building/have you built on hillsides, hilltops, landfills, in subsidence areas, or in flood zones? 14. Any work performed in the past using Exterior Insulation and Finish Systems (EIFS)? 15. Any work performed below grade? Maximum depth: Percentage of total work: 16. Is scaffolding owned, rented, or erected? Are other contractors at the job site allowed to use such scaffolding? 17. Do you have a formal safety program in force? Page 2 of 5

3 18. Any employees working under: a. U.S. Longshoremen s and Harborworkers Act? b. Jones Maritime Act? 19. Indicate the type of security used on a project: Fencing Lighting Watchman SECTION 3: SUBCONTRACTOR INFO/RISK TRANSFER 1. Do you utilize A.I.A. standard contracts for all of your subcontractors? 2. Are all subcontractors required to sign a hold harmless and indemnification agreement in your favor? If no, pelase explain: 3. Are Certificates of Insurance obtained from subcontractors for the following? (te: If not required, we cannot offer coverage.) General Liability: Minimum Limits Required: $ Workers Comp: 4. Are you named as an additional insured on all subcontractors policies? 5. Do you ever use uninsured subcontractors? 6. Do you normally use the same subcontractors? <31% of the time 31% - 50% of the time 51% - 100% of the time SECTION 4: CURRENT OR RECENT PROJECTS Project Description Cost of Project Duration SECTION 5: OTHER 1. Do you have a formal home warranty program? If yes, please provide details and attach copy of plan you provide to clients: 2. Do you have model homes? 3. Do you draw any plans or blueprints used in your construction work? 4. If yes, has Professional Liability coverage been obtained? Limit of Liability: $ 5. Do you own any vacant land (raw land with no developmental or improvement activity, held only for investment of possible development more than 12 months in the future. buildings on the property)? # of acres of vacant land: 6. Do you own any real estate development property completed or under construction (land with improvements streets, roads, or utilities, etc.)? # of acres real estate development property: Page 3 of 5

4 7. If yes to either vacant land or real estate development property, how is property zoned? Residential Commercial/Retail Industrial Other 8. Are other operations other than contracting? If yes, please describe: Where insured? 9. Are any operations insured elsewhere by an owner controlled insurance program (OCIP) also referred to as wrap-up insurance? 10. If yes, please provide details: 11. Do you have any other business ventures for which coverage is not requested? 12. If yes, please provide details: 13. Who is the bonding insurance carrier? Are they providing Contract & Surety bonds for you on behalf of your work? 14. Have you ever been involved in or are you currently aware of any pending litigation concerning construction defect? 15. Has the applicant or majority partner filed for bankruptcy within the past five years? SECTION 6: LOSS INFORMATION 1. Was prior coverage ever cancelled or non-renewed? 2. Loss information for the past 3 years: Losses Prior Coverage Year # of Claims Incurred Amounts Description SECTION 7: FRAUD WARNINGS, DECLARATION, SIGNATURES Applicable in Arkansas, Louisiana, and West Virginia Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Applicable in Colorado It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Applicable in District of Columbia WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Applicable in Florida Page 4 of 5

5 Any person who knowingly and with intent to injure, defraud, or deceive any insurance company files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Applicable in Hawaii For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. Applicable in Kentucky insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Applicable in Maine It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits. Applicable in Maryland Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Applicable in New Jersey Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in New Mexico Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject tocivil fines and criminal penalties. Applicable in New York insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Applicable in Ohio Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Applicable in Oklahoma WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Applicable in Pennsylvania insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Applicable in Rhode Island The insurance application form shall indicate the existence of a criminal penalty for failure to disclose a conviction of arson. Applicable in Tennessee, Virginia, and Washington It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. I hereby certify that all information is accurate to the best of my knowledge. Signatures: Date: Applicant: Signature Print Name Title Page 5 of 5